Controversies and evidence on Chlamydia testing and treatment in asymptomatic women and men who have sex with men: a narrative review

Abstract

Background Chlamydia trachomatis (CT) is the most common bacterial sexually transmitted infection (STI) worldwide. CT is mainly asymptomatic. Test-and-treat strategies are widely implemented to prevent transmission and complications. Strategies are not without controversy in asymptomatic women and men who have sex with men (MSM). Concerns are emerging to test and treat asymptomatic persons for urogenital CT (‘Controversy 1’) and pharyngeal or rectal CT (‘Controversy 2’), whereby testing symptomatic persons is not under debate. Opposed views in CT treatment involve using azithromycin versus doxycycline (‘Controversy 3’). The objective of this review is to provide coverage of these public health and clinical controversies by reviewing the current scientific evidence. Methods A literature search was performed using PubMed for relevant publications between 2018 and September 2021, and iterative retrieval of additional relevant publications. Results Controversy 1. In women, the majority of asymptomatic CT are at the urogenital site, and detections mostly include viable CT. CT easily transmits to a partner and potentially also between the vaginal and rectal areas; the clinical impact of urogenital CT is established, although risks for adverse outcomes are uncertain. Wide-scale testing in asymptomatic women has not resulted in reduced prevalence. In MSM, evidence for the clinical impact of asymptomatic urogenital CT is lacking. Controversy 2. Rectal CT is common in women diagnosed with urogenital CT, but the clinical impact of asymptomatic rectal CT is uncertain. In MSM, rectal CT is common, and most CT infections are at the rectal site, yet the risk of longer term complications is unknown. In both sexes, pharyngeal CT is uncommon and has no documented clinical impact. Controversy 3. In the treatment of rectal CT, doxycycline has superior effectiveness to azithromycin. Evidence has also accumulated on the harms of test-and-treat strategies. Conclusions Current practices vary widely, from widescale test-and-treat approaches to more individual patient- and partner-level case management. Choosing which asymptomatic people to test at what anatomic site, and whether to test or not, requires an urgent (re-)definition of the goals of testing and treating asymptomatic persons. Treatment guidelines are shifting toward universal doxycycline use, and clinical practice now faces the challenge of implementation.

Improving provider-initiated testing for HIV and other STI in the primary care setting in Amsterdam, the Netherlands: Results from a multifaceted, educational intervention programme

“…Therefore, extragenital infections are likely often being missed in primary care, particularly in women, possibly leading to suboptimal treatment. Nevertheless, the clinical relevance of asymptomatic extragenital chlamydia infections currently remains unclear [ 31 , 32 ].…”

Findings From a Scoping Review: Presumptive Treatment for Chlamydia trachomatis and Neisseria gonorrhoeae in the United States, 2006–2021

“…Chlamydia trachomatis, which is largely asymptomatic, relies on screening tests for diagnosis and treatment. 2 Among women, gonococcal infections are commonly asymptomatic or might not produce recognizable symptoms until complications (e.g., pelvic inflammatory disease) have occurred. 3 Currently, nucleic acid amplification tests are commonly used for the diagnosis of chlamydia and gonorrhea, and testing results can take several days to return.…”

“…3 In the absence of point-of-care (POC) testing (the first POC chlamydia and gonorrhea test was approved by Food and Drug Administration on March 30, 2021, and is not yet broadly used in the United States), treatment decisions are dependent on individual clinician discretion, leaving the potential for variability of presumptive treatment across care settings and health systems. 2 The approach is also not without risk, including increasing the potential for antibiotic resistance, increased health care costs, and adverse events (eg, allergic reactions). 4 However, underdiagnosis and undertreatment of these conditions remains a large concern for public health.…”

“…Chlamydia trachomatis , which is largely asymptomatic, relies on screening tests for diagnosis and treatment 2 . Among women, gonococcal infections are commonly asymptomatic or might not produce recognizable symptoms until complications (e.g., pelvic inflammatory disease) have occurred 3 .…”

“…Accordingly, the Centers for Disease Control Sexually Transmitted Diseases Treatment Guidelines include recommendations to presumptively treat CT and/or GC in persons with symptoms or known contact 3 . In the absence of point-of-care (POC) testing (the first POC chlamydia and gonorrhea test was approved by Food and Drug Administration on March 30, 2021, and is not yet broadly used in the United States), treatment decisions are dependent on individual clinician discretion, leaving the potential for variability of presumptive treatment across care settings and health systems 2 . The approach is also not without risk, including increasing the potential for antibiotic resistance, increased health care costs, and adverse events (eg, allergic reactions) 4 .…”